Problem Detailing
Local Issue
Upon implementation of the Geriatric Surgery Verification (GSV) standards it was noted that there were a lack of consultative services; such as geriatric services, palliative care, and home care.
Problem Statement
The targeted population included urgent or elective surgical patients, age ≥75, living in a rural community surrounding the Finger Lakes region of New York. This aging population continues to grow and will continue to be a vulnerable population, more so in a rural region due to the lack of community resources and specialty services. In order to seek appropriate services, it may require long-distance travel and/or increase the financial burden on these patients. This on-going problem is faced by many on a daily basis as they navigate the complex health care system. This program does not only identify surgical related problems, but financial and mental health issues, food disparities, lack of family/friend support, transportation issues, unsafe living environments, inappropriate medications/polypharmacy, etc. These are all things that should be addressed with patients prior to undergoing a major operation that could potentially affect their surgical outcomes. Data was captured from National Surgical Quality Improvement Program (NSQIP) and Qlikview (internal RRH data repository for GSV patients) for CSH and NWCH. Data was collected from Jan-Dec 2020 (pre-implementation) and Jan-Nov 2023 (post-implementation/verification). We used NSQIP as our source of truth, as it is manually abstracted by RNs, leading to superior accuracy. We cross-referenced our NSQIP data (including only patients age 75+) with our Qlikview data (showing all GSV patients).
Timeframe/population size:
Jan–Dec 2020: 264 patients (pre-implementation)
Jan–Nov 2023: 273 patients (post-implementation)
Results
- Pre-implementation 79.17% of the patients were being discharged home and about 19.32% went to rehab
- Post-implementation 83.5% of patients were being discharged home and about 15.4% being discharged to Rehab
- Orthopedic surgery had a 14% reduction in discharged to rehab.
- General and vascular surgery had a 10% reduction in discharged to rehab.
Aim Specification of QI Project
SMART Goal
The GSV program was rolled out over 2-3 years, which consisted of 6 phases. At the conclusion of the roll out, all GSV standards were met.
Strategic Planning
Description of QI Activity
Implementation of the GSV program at CSH and NWCH.
Description of Intervention
When the decision was made to start the GSV program, there was a kick–off meeting, followed by the creation of working groups. This included the core team members of GSV and internal stakeholders who met on a weekly basis to develop a plan on how to roll out each standard. A gap analysis was performed and discussion included identifying areas of strengths and areas for opportunities. Following these meetings, information was cascaded through small group education sections, e-mail and verbal communication.
Core team:
- Medical director of geriatric surgery
- Geriatric medicine director
- Geriatric surgery program manager
- Surgical quality project manager
- Geriatric APP/MD’s
- Geriatric surgery nurse champions
- Multidisciplinary working group team
- Core team members (listed above)
- Hospital medicine group
- Anesthesia group
- Surgical group (surgical APP/ MD)
- Geriatric consultation group
- Telemedicine group
- Hospital administration/leadership
- Palliative care consultation group
- Clinical staff (RN/LPN, PCT, PT, OT, SLP, RT)
- Social work/case management team
- Nutrition/dietician
- Pharmacists
- IT analyst
Outcome Evaluation
Final or Most Current Results
- Post–implementation 83.5% of patients were being discharged home and 15.4% were being discharged to rehab.
- Overall, there was a 4.3% increase in patients being discharged home after surgery when enrolled in the geriatric surgery verification Program
- Orthopedic surgery had a 14% reduction in discharge to rehab.
- General and vascular surgery had a 10% reduction in discharge to rehab.
- GYN, ENT and urology maintained a discharge rate to home of 100%.
Limitations/Setback
The Covid pandemic delayed implementation, affected staffing, and lowered volume of elective surgical patients with elective surgeries being cancelled due to New York State regulations.
Cost, Resources, and Value Evaluation
Cost of Project:
- 0.25 FTE for project manager
- 0.5 FTE program manager
- 0.25 FTE program director
- 1.0 FTE geriatric provider (This could be dependent on population size, if greater than 1200 patients/year consider additional FTE)
- IT costs
- Telemed costs
Team and Stakeholders’ Perspective on Value
This program focuses on the quality of care that is provided to the patients instead of the quantity of patients going through the program. Each patient is evaluated to identify their individual risks in order to create a patient-centered and patient-focused plan of care. The GSV program improved patient outcomes by decreasing post-op complications, improving patient and family satisfaction by helping them achieve their goals of care, and helping them remain home after surgery. This type of program should be the standard of care for not only geriatric patients, but all surgical patients who are high risk of post-op complications.
Resources Used:
- Core team members
- Borrowed resources for staff (time commitment)
- Medical Equipment- Eli box (stores sensory devices), Telemed cart
- IT Support- build and develop
- Multimedia- brochures
Knowledge Acquisition
Key Takeaways
- IT support/IT build is critical for the success of program implementation; assists with identification of patients, reminders to staff and overall program compliance.
- Goals of care discussion and advanced directives need to become a standard of care in the surgeon’s office. The conversation needs to start early and may want to consider making this a required component of documentation.
- Program leadership with a strong knowledge of the standards is imperative to program success.
- Early post-operative intervention with therapies (PT/OT/SLP/Nutrition) can help improve discharge to home.
- Future GSV work should include a thorough psychosocial assessment to evaluate the patient’s support network, home environment, and mental health to better predict a successful discharge to home post-operatively.
Problems Encountered
Covid pandemic delayed implementation, effected staffing, lowered volume of elective surgical patients with elective surgeries being cancelled due to NYS regulations.
End-of-Project Decision-Making
Future Actions
Based on the success of this program at three level 1 geriatric surgery verified hospitals, we have been able to replicate it at 2 additional hospitals in our health care system; hoping to become formally verified in 2025-2026.
Post-Project Plan
This quality program is currently sustained at NWCH and CSH by the GSV nurse champions, geriatrics APP, and program manager on a daily basis; but it would not be possible to maintain this program without the internal stakeholders who are involved in the pre-op, intra-op, and post-op phases of care. Outcome measures are being reviewed on a quarterly basis with the core team and internal stakeholders. These outcomes are being collected from an external database (NSQIP) and an internal database (Qlikview); which is cross referenced and validated by a core team member.
